Overview and CQC Inspections

OverallGood

Our inspector's description of this service

Last updated 6 August 2016

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

The inspection took place on 20, 21 and 22 June 2016 and was unannounced. The inspector was assisted by a specialist advisor, with a nursing background in working with people with dementia and those receiving end of life care, and an expert by experience. An expert-by-experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Before the inspection, the provider completed a Provider Information Return (PIR). This is a form that asks the provider to give some key information about the service, what the service does well and improvements they plan to make. We looked at the PIR and at all the information we had collected about the service. This included previous inspection reports, the provider's statement of purpose for the service, information received and notifications the registered manager had sent us. A notification is information about important events which the service is required to tell us about by law.

During the inspection we spoke with 16 people who use the service, five of them in private, and three relatives. We spoke with the registered manager, two registered nurses and six care workers. We also spoke with the chef, a kitchen assistant, the administrator and the maintenance person. We observed interactions between people who use the service and staff during the three days of our inspection. We spent time observing activities and lunch in the dining room. As part of the inspection we requested feedback from 12 healthcare professionals and seven social care professionals. We received feedback from three healthcare professionals and one social care professional.

We looked at four people's care plans, monitoring records and medication sheets, four staff recruitment files, staff training records and the staff supervision log. Medicines administration, storage and handling were checked. We reviewed a number of other documents relating to the management of the service. For example, the electrical equipment safety check log, the legionella risk assessment, the fire risk assessment, pressure mattress checks and the complaints and incidents records.

Inspection ratings

We rate most services according to how safe, effective, caring, responsive and well-led they are, using four levels:

Outstanding – the service is performing exceptionally well.

Good – the service is performing well and meeting our expectations.

Requires improvement – the service isn't performing as well as it should and we have told the service how it must improve.

Inadequate – the service is performing badly and we've taken enforcement action against the provider of the service.

No rating/under appeal/rating suspended – there are some services which we can’t rate, while some might be under appeal from the provider. Suspended ratings are being reviewed by us and will be published soon.

Ticks and crosses

We don't rate every type of service. For services we haven't rated we use ticks and crosses to show whether we've asked them to take further action or taken enforcement action against them.

There's no need for the service to take further action. If this service has not had a CQC inspection since it registered with us, our judgement may be based on our assessment of declarations and evidence supplied by the service.

The service must make improvements.

At least one standard in this area was not being met when we inspected the service and we have taken enforcement action.